COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PROBATE COURT OF TRUMBULL COUNTY, OHIO THOMAS A. SWIFT, JUDGE:::::::Index No.Calendar No.IN THE MATTER OF THE GUARDIANSHIP OF CASE N0. JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)STATEMENT OF EXPERT EVALUATIONDefinition of Incompetent (R.C. 2111.01(D)): Incompetent means any person who is so mentally impaired as a result of a physical or mental illness or disability, or retardation, or as a result of chronic substance abuse, that he is incapable of taking proper care of himself or his property or fails to provide for his family or other persons for whom he is charged by law to provide, or any person confined to a penal institution within this State. The Statement of Evaluation does not declare the prospective ward competent or incompetent, but is evidence to be considered by the Court.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TOThe fee for completing this evaluation WILL NOT be paid by the Court. Each evaluator should secure payment from the Applicant/Guardian. 1. This Statement of Evaluation is for: Guardianship Application. (To be completed by a Licensed Physician or Licensed Clinical Psychologist, and attached to the Application).GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofGuardian's Report. (Evaluation and Statement by a Licensed Physician, Licensed Clinical Psychologist, Licensed Social Worker, or Mental Retardation Team to be completed within three months of date of the report. R.C. 2111.49(A)(1)(i).)o'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in room2. Statement completed by: (please type or print)Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.Name: Address: Phone Who is a: Licensed Physician, one of the Justices of theCourt in Witness, Honorableday of, 20 County, Licensed Clinical Psychologist Licensed Social Worker Mental Retardation Team(Attorney must sign above and type name below)3. Following is my diagnosis/assessment of the mental and physical capacity, and the functioning level of the prospective ward. Attorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:9/1/91FORM 17.1 STATEMENT OF EXPERT EVALUATIONAmerican LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CASE NO. :::::::Index No.Calendar No.4.Is the prospective ward mentally impaired?Yes No 5.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)A. Is there observed or reported evidence of mental impairment? Yes No Describe: B. If reported, name source: 6.If the prospective ward is mentally impaired, what is the cause? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7.A. Is there observed or reported evidence of physical impairment? Yes No Describe: THE PEOPLE OF THE STATE OF NEW YORK TOB. If reported, name source: 8.Can the prospective ward conduct business affairs without the aid of a guardian? Yes No Comments: 9.GREETINGS:Can the prospective ward properly care for himself without the aid of a guardian? Yes No Comments: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,10.located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in room(TO BE COMPLETED IF SUBMITTED WITH A GUARDIAN'S REPORT) In my opinion, the guardianship should be: Continued Terminated .11.(TO BE COMPLETED IF SUBMITTED WITH AN APPLICATION FOR GUARDIANSHIP) In my opinion, the application for guardianship: Should be granted Should not be granted .Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.ADDITIONAL COMMENTSI certify that I have evaluated for the purpose of guardianship., one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)Attorney(s) forDate of Evaluation EvaluatorOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:9/1/91FORM 17.1 STATEMENT OF EXPERT EVALUATIONAmerican LegalNet, Inc. www.USCourtForms.com
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